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AIRWAY MANAGEMENT AFTER CERVICAL SPINE INJURY

AIRWAY MANAGEMENT AFTER CERVICAL SPINE INJURY. DINO A. O. ALTMANN, M.D. HOSPITAL SÃO LUIZ BRAZIL. Airway management after cervical spine injury. CERVICAL SPINE INJURY x HEAD INJURY. 14,755 ADMISSIONS 292 (2.0%) CERVICAL SPINE INJURIES GLASGOW COMA SCALE CSI 13 – 15 1.4%

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AIRWAY MANAGEMENT AFTER CERVICAL SPINE INJURY

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  1. AIRWAY MANAGEMENT AFTER CERVICAL SPINE INJURY DINO A. O. ALTMANN, M.D. HOSPITAL SÃO LUIZ BRAZIL

  2. Airway management after cervical spineinjury CERVICAL SPINE INJURY x HEAD INJURY 14,755 ADMISSIONS 292 (2.0%) CERVICAL SPINE INJURIES GLASGOW COMA SCALE CSI 13 – 15 1.4% 9 – 12 6.8% ≤ 8 10.2% Demetriadesetal J Trauma, 2000

  3. Airway management after cervical spineinjury CERVICAL SPINE INJURY x HEAD INJURY 447 HEAD INJURIES 24 (5.4%) CERVICAL SPINE INJURIES Holly etal J Neurosurg, 2002

  4. Airway management after cervical spineinjury CERVICAL SPINE INJURY34,069 BluntTaumaVictims 818 CERVICAL SPINE INJURIES 2.4% C2 24.0% C6 + C7 39.3% NOT CLINICALLY SIGNIFICANT 29.3% Goldberg W etalAnnEmergMed, 2001

  5. Airway management after cervical spineinjury CERVICAL SPINE INJURY STABLE UNSTABLE Instabilityoccurswhenphysiologicloading causes patternsof vertebral displacementthatjeopardizethespinalcordornerveroots

  6. Airway management after cervical spineinjury CERVICAL SPINE INJURIESNotclinicallysignificant (NEXUS) • Spinousprocessfractures • Wedgecompressionfractures ≤ 25% body • Isolatedavulsionwithoutligamentinjury • Type I odontoidfracture • End-platefractures • Isolatedosteophytefractures • Trabecularfractures • Isolatedtransverseprocessfractures Goldberg W etalAnnEmergMed, 2001

  7. Airway management after cervical spineinjury MECHANISMS OF SPINAL INJURYHyperextensionandHyperflexion

  8. Airway management after cervical spineinjury MECHANISMS OF SPINAL CORD INJURY Primaryshear forces compression distracting forces bonefragments SecondaryFAILURE TO IMMOBILIZE THE SPINE IN NEUTRAL POSITION local perfusiondeficit systemichypotension hypoventilation increasedvena cavapressure

  9. Airway management after cervical spineinjury MANUAL IN-LINE IMMOBILIZATIONMILI

  10. Airway management after cervical spineinjury “NEUTRAL POSITION” 2.0 cm OCCIPUT ELEVATION INCREASES SPINAL CANAL/SPINAL CORD RATIO AT C5-C6 De Lorenzo etal, AnnEnergMed 1996

  11. Airway management after cervical spineinjury MILI x CERVICAL COLLAR DuringLaringoscopy Lessspinalmovement Improveslaryngealvisualization

  12. Airway management after cervical spineinjury CERVICAL SPINE INJURYClinicalPredictors SEVERE HEAD INJURY FOCAL NEUROLOGICAL DEFICIT

  13. Airway management after cervical spineinjury URGENT AIRWAY INTERVENTIONBlunt Trauma Patient LESS LIKELY to have a complete neurologicalevaluation MORE LIKELY neurologicalinjury SUSPECT CERVICAL SPINE INJURY

  14. Airway management after cervical spineinjury ANTERIOR LARYNGEAL OR CRICOID PRESSURE Improveslaryngealvisualization Do not cause upper cervical spinemovement Protectsagainstaspiration

  15. Airway management after cervical spineinjury SPACE AVAILABLE FOR THE SPINAL CORDSAC

  16. Airway management after cervical spineinjury CERVICAL MOTION DURING AIRWAY MANAGEMENT MostsignificantatOc – C1

  17. Airway management after cervical spineinjury MASK VENTILATIONxTRACHEAL INTUBATION More cervical spinemovement withmaskventilation

  18. Airway management after cervical spineinjury COMPARABLE SPINAL MOVEMENT Directlaringoscopy Video-laryngoscopy (Glidescope) Nasotrachealintubation Laryngealmaskinsertion Combitubeand PTL Cricothyrotomy Flexiblebronchoscopeintubation

  19. Airway management after cervical spineinjury AIRWAY MANAGEMENT AT SCENE

  20. Airway management after cervical spineinjury PHARYNGEAL – TRACHEAL LUMEN AIRWAYPTL

  21. Airway management after cervical spineinjury PHARYNGEAL – TRACHEAL LUMEN AIRWAYPTL

  22. Airway management after cervical spineinjury PHARYNGEAL – TRACHEAL LUMEN AIRWAYPTL

  23. Airway management after cervical spineinjury PHARYNGEAL – TRACHEAL LUMEN AIRWAYPTL

  24. Airway management after cervical spineinjury AIRWAY MANAGEMENT AT MEDICAL CENTER CONSIDER FLEXIBLE BRONCHOSCOPE INTUBATION

  25. Airway management after cervical spineinjury CONCLUSIONS Lackofprospectivestudies Apply MILI for allairwaymaneuvres Avoidface-maskventilation Rapidsequenceintubation Comparableairwaymethods Tailorandfollowyourown ALGORITHM

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